The Mammography Debate: Dr. Weiss weighs in with the WSJ

Moderators

Read the blog post about Dr. Weiss's interview with The Wall Street Journal or read the article here. Don't forget to weigh in with your thoughts!

voraciousreader

I read Dr. Welch's book. I agree with him with respect to patients need to fully understand their risk vs. benefit ratio with regard to screening. Furthermore, I think more patients should heed the recommendations coming out of the U. S. Preventative Task Force. Reading American Cancer Society's Otis Brawley, MD's How We Do Harm, I've enlightened myself with respect to "rational" health care. I applaud books like Welch's and Brawley's because we've been led to believe that all screening is good. We need an articulation on exactly how "good" screening actually is AND how much of it we really need. My 87 year old mother is still invited to have mammograms and sonograms despite comorbidities that would preclude her from having surgery. During her lifetime she has had numerous biopsies. It appauls me that at her advanced age she is frightened at the thought of having a mammogram and at the same time she is frightened about not having screening. Dr. Brawley is right! We need rational health care and that begins with biostatisticians like Dr. Welch stepping up to the plate and calling for a time out!

coraleliz

Just curious with this question of mine.

Mamograms were recommended for women starting at age thirty, when I got my 1st "annual" back in 1988. Was there an outcry when it changed to age 40 & I just missed it. Were the same arguments used?

Being mamomgram-intolerant, years of procedures left me putting off anything breast related. Mamograms, I'd put off until til 18months or 2 years. I flat out refused the steriotatic biopsy-can't tolerate compression plates. Not sure if anyone else can relate to my post, but for me less would have been better. I don't know what I'd think if I had a more aggressive BC, but I do believe Dr Welch is speaking to situations like mine, where early detection may not matter.

voraciousreader

Coraliz....I was 31 back in 1988, and I don't recall there being a recommendation to begin screening at age 30.  I began having mammograms at age 40 and two years after that, I began adding sonograms because my breasts were too dense and the mammograms were deemed, "useless."  A sonogram picked up my mucinous tumor.  The argument regarding when to begin mammograms didn't erupt until the U.S. Preventitive Services Task Force recommended for MOST women to begin screening at age 50 rather than  age 40.  It wasn't a hard and fast recommendation.  However, the recommendation was explicit.  It told patients to discuss with their physicians their risk/benefit ratio and then decide at what age it would be appropriate for them to begin screening.  Likewise, the Task Force also mentioned at what age one could consider forgoing screening.  Again, they made the recommendation based on statistics AND the following info.  First, mammograms were not as good of a modality for detecting breast cancer in women who had dense breasts, and those women were mostly under age 50 and premenopausal.  The statistics also showed that for many younger women, because their cancers were aggressive, many were being identified EARLIER through mammography, but subsequently would succumb to the disease.  The Task Force noted that mammography was best for women between the ages of 50-75 because they were the most at risk of getting breast cancer and while the mammograms were better at finding the tumors, they were usually more treatable.  Of course we now have better treatments available for ALL breast cancer patients and the survival rates reflect that.  But according to Dr. Welch and his colleagues, the reason why more patients survive breast cancer is due to better TREATMENTS and not so much due to screening.  I might add, Dr. Welch's wife is a breast cancer survivor!  What Dr.Welch also found was that DIAGNOSTIC screening is EFFECTIVE.  That is, when a patient has a breast SYMPTOM and has screening, THAT saves lives.  In fact, Dr. Welch's wife had had her regular mammogram several months before she discovered her lump.  A DIAGNOSTIC mammogram found her tumor.

So basically, the "argument" is about explaining to patients WHY and WHEN they should have screening based on their risk factors.  Unfortunately, in the real world there usually is NO articulation.  You go to your doctor and they just right you a perscription without discussing your history and risk factors.  Dr. Welch and Dr. Brawley advocate for a discussion of the evidence before writing that perscription.

Here's a great, balanced, IMHO, article on the controversy:

http://www.cnn.com/2012/11/21/health/mammogram-study

And here's the latest "evidence" regarding older women:

http://www.reuters.com/article/2013/02/07/us-health-mammogram-idUSBRE91614020130207

And here's a great podcast with Dr. Brawley.  Begin listening at 6 minutes:

click here if you cannot view audio player: PP-870.mp3

cooka

A few things struck me about Dr. Welch’s perspective.  First, I usually try not to do math in public, but, stated another way, 1 out of 1000 women over the age of 50 in the United States is AT LEAST 37,000 women.   I think this is a significant amount of women, even if Dr. Welch tried to minimize it in the way he presented his statistics. I think it is important to talk about that number in a forthright way.

The idea that one of the major harms Dr. Welch discusses that result from  screenings are false alarms in which some women will “never be reassured” seems a bit patronizing to me.  Taken in another context, terrorism has resulted in far less than 37,000 deaths in the last decade (actually 30,000 less US deaths since the 1920’s) yet we all submit to “upsetting” and coercive screenings every time we fly, and we have resigned ourselves to a variety of other reductions in civil liberties to save American lives.  Some may argue this is also an overkill response, but my point is, that as a society, we generally value life to the extent that we will spend billions and put up with all sorts of “coercion” for far less than 37,000 lives each decade.

Another of Dr. Welch’s points is that we are screened and have procedures for cancers that may not have killed us anyway.  Many of us submit to annual cholesterol screenings and blood pressure checks, and might live under the stress of knowing we have high cholesterol without being able to say for certain that our cholesterol will actually cause us to have a stroke or heart attack…yet we choose to do what we can to reduce the threat (even if it means taking medication that may have many adverse, long-term effects).   Until we know more about cancer and can predict for certain how a certain type will impact us, we should not be encouraged to bury our heads in the sand by not getting screened.  Perhaps after the positive screening, physicians can do more to educate patients on options and consequences of treatment (and I agree this should be an area for emphasis).  Ignoring the reality that there are potential health threats identified by the screening (or that have gone unidentified by not screening) does not seem to be how we address a whole host of other health threats, why start with this one?

I think the idea that we should not coerce or “guilt” women into medical procedures (screenings or otherwise) is generally a good one (plastic surgery, for example).  However, what troubles me is what that will look like in policy, because that is after all, Dr. Welch’s bailiwick.  For many women, a policy that mammograms are “coercive, harmful or unnecessary” means they will not have access to them at all, because insurance can get away without paying for them.  That, to me, will result in a truly coercive result wherein a women who chooses to brave the “harmful” and unsettling world of preventative screening will be unable to do so if she chooses.

voraciousreader

Cooka... Breast cancer screening isn't the only screening that is being questioned. Prostate screening has been questioned and most recently annual check-ups as well. Please don't get me started on cholesterol screening or bone density screening either. Considering that 50% of people who get heart attacks have normal cholesterol numbers, physicians should be better advising their patients regarding the NCEP guidelines to determine a patient's risk before prescribing a statin. Most people have never heard of the NCEP guidelines and have no idea what % risk they have of getting a heart attack in the next 10 years, but can easily recall their cholesterol numbers. I think Dr. Welch and his colleagues are doing a great job of trying to enlighten patients how to become BETTER patients... and I think it's all about each individual understanding their risks for certain diseases and getting screened accordingly.

cooka

Yes, I see where you are coming from, but how does this translate to policy and insurance coverage? At the heart of this is a policy debate that has financial implications (that disproportionately impact lower socioeconomic groups), not a debate about educating individuals. If you as a doctor educate me and I still want screening, I can potentially pay for my own.  Some people may not have the ability to do so, and we would be forcing them to take an action that for other people is optional.

voraciousreader

Cooka...before we get to the policy and insurance coverage implications, patients and physicians alike need educating. You mention that people who have the means to be screened are less effected. However, if you read Dr. Brawley's book, he drives home the point that more screening and more treatment does NOT imply better care. So before we can have an educated discussion about policy, we need a more informed discussion about care.

cooka

Hi Voraciousreader,

Actually, no, I am not saying that people who have the ability to be screened are "less effected."  I am saying that once they are educated, and make a choice based on this education, they have a choice because they are not limited by financial ability.  If the insurance companies get their way and have us buy into this "its better for you not to be screened" sales pitch, women (collectively) will have fewer choices in their healthcare. That, to me, is a move backward, not forward.  Present your evidence that you think should convince me that a screening is pointless, fine...but at the end of the day the decision should still be mine. The idea that we shouldn't get mammos at 40 because they will stress us out however, is jut silly in my opinion: there are alot more stressful things women deal with on a daily basis than mammos (I do realize there is alot more to the argument than that, however). 

voraciousreader

Cooka...you are making unnecessary sweeping generalizations.  No one is saying that "stressing" a person should be a reason NOT to be screened.  What I was referring to, in my mother's situation, was that there was NO evidence that supported that at her advanced age, that a screening mammogram is necessary.  However, my mother, who by the way is well educated, was taught that if you are screened, then you would catch a cancer early and then it would be more treatable. So for the last 40 something years she's had annual screenings.  All Dr. Welch is saying, by presenting this data, is that yes, you can catch a cancer early with SOME screening.  But the number of  cancers that can be caught that are life saving are not as many as thought.  Recall that a decade ago, the standard of care was that when most women were diagnosed with breast cancer they would receive chemotherapy.  Today, for many patients we have genetic screening both before a diagnosis and following a diagnosis that helps a woman with assessing her risks and benefit of screening as well as treatment.  The shift from moving away from chemotherapy is monumental.  But it couldn't have occurred without first acknowledging that physicians were OVER treating patients.

Hopefully, in the near future, researchers will come up with better modalities for identifying and treating breast cancer AND THAT'S WHERE WE WILL SEE THE FINANCIAL SAVINGS without compromising choice. While the OncotypeDX test costs thousands of dollars, the cost of forgoing chemo is an even GREATER savings...both financially and in improving one's quality of life.  For sure, there will still be women who are going to want chemotherapy because they are risk adverse, and that's okay.  But we need to understand that we must accept the limitations of screening and move on to a more enlightened view.  Only that way will there be progress....

cooka

I think a sweeping generalization (since you bring it up ) worth mentioning here is one that concludes that by finding cancer in screenings that we are unsure of the prognosis of, we are "over diagnosing" cancer. A further sweeping generalization might be that since mammography is "doing more harm (over diagnosing cancer)" than good, it is ineffective and should not be offered routinely to certain age groups. Researchers still don't know how to sort out which of these cancers (that no one has stopped calling cancers) are over diagnosed.  Was my TN Grade 3 cancer, found at age 41, over diagnosed?  Would I have had a mammogram through Tricare that discovered it if we decided as a society that finding cancers we don't exactly know how to deal with is less preferable to identifying these risks early? I don't think you can successfully argue that having cancer, even when the prognosis is unknown, is not a health risk.  I agree that we should get cracking looking for progress in prevention, treatment, etc., but as the Harvard study concluded, "for every 2,500 women invited to screening, only one life will be saved."  Wow, "only"? That is a crap load of women, particularly when weighed against the "harms of unnecessary surgeries and treatments (we don't know which ones were unnecessary!) to emotional distress". Again, I understand what you are saying, and if this was an easy question it wouldn't be so hotly debated, but the data presented so far is not compelling enough for me to accept a position that insurance companies are drooling over themselves to get us to agree to. I understand the need to contain health care costs, but I am not convinced this is the way (and I am cynical enough to believe that there is far more to this debate than a desire to "educate" women).  

 

voraciousreader

Cooka... Plain and simple, this is about rational healthcare. It is not about rationing healthcare. And as long as society takes the point of view of cynicism, we will not be able to have a healthy debate.

MelissaDallas

I didn't have a mammogram between my baseline at 40 and when I turned 50 because I assessed my risk factor as low and I tend to agree about the too many false alarms. It wouldn't have made any difference with LCIS. I have read in all this info somewhere that a big percentage of women who are diagnosed young from a mammogram have been sent for a mammogram because they have found a lump or other symptoms.

voraciousreader

Melissa... What you are referring to is a DIAGNOSTIC mammogram and they save many lives.

cooka

Voraciousreader,

Cynicism with regard to corporate motives is not necessarily irrational, ya know (although a favorite fall back position for many in this argument is to point out that women who feel differently about it are irrational). For now, until I see more convincing evidence, we will have to agree to disagree.  Cheers, Anne

voraciousreader

Cooka... Perhaps you could read Dr. Welch and Dr. Brawley's books and then see if you feel differently. Another terrific book is Eric Topol, MD's, The Creative Destruction of Medicine. Dr. Topol believes that in the coming years, technology is going to revolutionize medicine. Read his book and see how individualized medicine is going to revolutionize the delivery of medicine. Read how clinical trials will be more individualized. Monitary savings are not going to come via denying services. In fact, with technology and more genetic based screening we are going to save more money AND lives.



Read the books! And then tell me if you think differently. Good luck!

MelissaDallas

Yes, Voracious, I was trying to say that most are found on diagnostic rather than just the regular screening.

gillyone

I am with Dr Welch on this issue. For example, in England, women do not get routine screening mammograms until age 50, and then only every three years from then on. The incidence of breast cancer is no greater in England than it is here.

voraciousreader

Op-Ed

Your annual screening may cause you more harm than good.

February 21, 2013|By H. Gilbert Welch

"There is growing evidence that screening mammograms aren't all they've been cracked up to be. This month it was "More mammograms, more problems" — a study showing that screening every year (instead of every other) didn't produce any benefit but did produce twice as many false alarms and twice as many biopsies. A few weeks earlier, another study (which I coauthored) suggested that roughly one-third of breast cancers diagnosed under current screening guidelines would never cause problems and didn't actually need to be diagnosed.

There's no question that diagnostic mammograms should be performed on women who have discovered a lump. But a growing number of primary-care physicians, surgeons, epidemiologists and women affected by the process have begun to question the value of telling all women they need to be checked regularly with screening mammograms. We are concerned about the human costs of screening: the fear created by the scare tactics used to promote it, the vulnerability caused by false positive or indeterminate test results ("it's not cancer, but it's not normal") and the complications that result from overdiagnosis and overtreatment.

Recently a reporter asked me a deceptively simple question: What are people like you trying to do?

To answer this, it's important to be clear about two things we are not trying to do: 1) stop women from getting screened and 2) prompt insurance companies to stop covering screening. Women who want to be screened should be. And because health insurance already covers many preference-sensitive services — services like hip replacements and back surgery — there is no reason it should not cover this one.

What we are trying to do is two things.

First, we want to give women the opportunity to make a choice. Screening mammography should be presented as an option, not as a public health imperative. To make that choice, women need to be given balanced information about its benefits and harms.

That is not current practice. Instead, women are subjected to persuasive messages that overstate the benefits while ignoring the harms entirely. There are the constant reminders, phrases such as "Screening saves lives. Get screened." And there is also guilt and coercion aimed at those who opt out ("I can't be your doctor if you refuse to get one").

One big reason this occurs is that the proportion of women who get screened has been a long-standing performance measure in healthcare report cards. Health systems that score high on report cards are judged to have higher quality — and, increasingly, they are also paid more. Not surprisingly, they push their doctors to push mammography. The typical language is "we need to improve screening compliance."

But the system's interest in getting good grades shouldn't trump a woman's interest in having a choice. Fortunately, the fix is easy: Drop the screening mammography performance measure.....

........There is a fundamental asymmetry to screening: Only a very few can possibly benefit (those women who would die if their breast cancer wasn't detected and treated), but any participant can be harmed. It requires a more elegant approach, one that finds the cancers that matter while minimizing the collateral damage.

There is no question in my mind we could preserve whatever benefits exist in mammography screening while reducing the harms. But that will never happen until the mammography community acknowledges that the harms exists."

http://articles.latimes.com/print/2013/feb/21/opinion/la-oe-welch-too-many-mammograms-20130221

chrissilini

I haven't read the article or the book yet. I agree that people need to be educated about the risks vs benefits of any medical testing. I had my baseline mammo when I was 40. No risks factors other than being overweight. And here I am. Although my IDC was small, what would it have been if I had waited until I was 50?



I think each individual has to look at the whole picture and decide what's best for them. There is no one time, procedure, protocol that covers everyone. It's your decision and you need to be your own advocate.

SharonElaine

So what is the research on thermography screening for breast cancer detection? It seems so much safer than mammography if it is effective.

voraciousreader

http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm257259.htm

The above link is a statement from the FDA regarding Thermography screening.

IMHO....As long as we continue with the mantra of "Annual Mammography Screening Saves Lives" and not fully understand that yes, annual mammography screening does save lives, but not as many as we are led to believe, then newer technologies will take LONGER to be discovered.

We need types of annual screening for many disorders that are safe and EFFECTIVE.  Sadly, the controversy regarding screening mammography will continue as long as the status quo is in place.....

And for the record...a DIAGNOSTIC sonogram found my tumor.  It was missed on my annual screening mammogram AND sonogram.